Deadly serious – coroner’s inquest


medicolegalAn inquest is a fact-finding exercise co-ordinated by the coroner (or procurator fiscal in Scotland), with or without a jury. The objective is to determine who died, when, where and how they died, and in what circumstances. Evidence is given by witnesses under oath. An inquest is a court of inquiry and is not held to apportion blame. There are no opposing parties, and no formal allegations or pleadings, but witnesses have the right to representation.


Referring deaths to the coroner

Deaths must be reported to the coroner in certain circumstances including:

  • Violent death
  • Death where a doctor has not attended in the last 14 days (28 days in Northern Ireland)
  • Cause of death is unknown/uncertain
  • Accidental death
  • Death related to surgery or anaesthetic
  • Death within 24 hours of hospital admission

Writing a report

If you are involved in the care of a patient whose death is reported to the coroner, you might be asked to write a report, or even to give evidence. In these circumstances you will be “a witness of fact” – ie, you will only be asked to give the facts as you know them.

Your report should be straightforward and written in the first person, and you should describe what happened – what you did, what other people did, etc – without speculating about or commenting on others’ motivations. The structure should be simple:

  • First paragraph: who you are (including your qualifications, experience and post) and where you work.
  • Subsequent paragraphs: the sequence of events you are being asked to report on, including the names and roles of other people involved. Be as accurate as possible about dates and times and use a separate paragraph for each occasion you saw the patient. Include information about history taking, examination, differential diagnosis, investigations, management plan, etc.
  • End with a signed and dated statement of truth: “I believe the facts in this report are true.”

Before submitting it, proofread your report to check that it is complete and accurate and remember to keep a copy.

Giving evidence


If you are called as a witness, the best preparation you can make is to read through the medical record and your report beforehand. Make sure you know your facts. Find out where the court is and how long it will take to get there. Check with the legal services department of your trust (or if you are being separately represented, with your medical protection organisation) whether the family will be legally represented, and whether the coroner has particular concerns about the case.

On the day

  • Allow yourself plenty of time for your journey, dress appropriately, and bring the medical records and/or your report with you.
  • When giving evidence, keep to the facts, answer the questions, and confine your comments to your area of expertise.
  • In most cases you will not, as a junior doctor, be asked to give an opinion.
  • Remember to address your answers to the coroner.
  • Appearing as a witness at an inquest may seem like an ordeal, but the reality won’t be that bad. If you are worried, ask the legal services department of your trust or your medical protection organisation for advice.

You can find more advice from the MPS at